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ID

43105

Descrizione

Southwest Oncology Group Registration Form (17418) NCT00020709 S0023: Combination Chemo Plus RT With or Without Gefitinib in Treating Patients With Unresectable Stage III NSCLC Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CA62D43-4B63-361C-E034-080020C9C0E0

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9CA62D43-4B63-361C-E034-080020C9C0E0

Keywords

versioni (4)
  1. 19/09/12 19/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
  3. 29/06/15 29/06/15 -
  4. 20/09/21 20/09/21 -
Caricato su

20 settembre 2021

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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    Southwest Oncology Group Registration Form (17418) NCT00020709

    Inglese

    No Instruction available.

    1 moduli  
    1. StudyEvent: Southwest Oncology Group Registration Form (17418)
      1. No Instruction available.
    SWOG clinical trial administrative data
    Descrizione

    SWOG clinical trial administrative data

    SWOG Study No.
    Descrizione

    SWOGStudyNo.

    Tipo di dati

    text

    Registration Step
    Descrizione

    RegistrationStep

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ValueDomain-2
    C16154
    UMLS 2011AA ValueDomain-2
    C1704379
    Treatment Arm Number
    Descrizione

    Protocol Treatment Arm

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1522541
    NCI Thesaurus Property
    C32141
    NCI Thesaurus ObjectClass
    C15368
    Activation Date
    Descrizione

    ActivationDate

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C64382
    UMLS 2011AA Property
    C1879547
    NCI Thesaurus Property-2
    C41200
    UMLS 2011AA Property-2
    C0680532
    Last Amended Date
    Descrizione

    DataAmendedLastDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    NCI Thesaurus ValueDomain-2
    C25551
    UMLS 2011AA ValueDomain-2
    C1517741
    Patient's Name
    Descrizione

    Patient'sName

    Tipo di dati

    text

    SWOG Patient ID
    Descrizione

    SWOGPatientID

    Tipo di dati

    text

    Other Group Identifier Code
    Descrizione

    OtherGroupIdentifierCode

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus ObjectClass-2
    C17005
    UMLS 2011AA ObjectClass-2
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Protocol Participating Identifier Number
    Descrizione

    Study Number Participating Group

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Caller's SWOG Roster ID
    Descrizione

    Caller'sSWOGRosterID

    Tipo di dati

    text

    Alias
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C25699
    UMLS 2011AA Property-2
    C1519429
    NCI Thesaurus ObjectClass
    C25357
    UMLS 2011AA ObjectClass
    C0557514
    IRB Approval Date
    Descrizione

    IRBApprovalDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25425
    UMLS 2011AA Property
    C0205540
    Projected Start Date of Treatment
    Descrizione

    ProjectedTreatmentBeginDate

    Tipo di dati

    date

    Date Informed Consent Signed
    Descrizione

    InformedConsentDateSigned

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    SWOG Investigator Number
    Descrizione

    SouthwestOncologyGroupInvestigatorIdentifierNumber

    Tipo di dati

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass-2
    C17089
    UMLS 2011AA ObjectClass-2
    C0035173
    Other Group Investigator Name
    Descrizione

    OtherGroupInvestigatorName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass-2
    C25936
    UMLS 2011AA ObjectClass-2
    C0035173
    NCI Thesaurus ObjectClass-3
    C43359
    UMLS 2011AA ObjectClass-3
    C0441833
    Other Group Investigator Number
    Descrizione

    OtherGroupInvestigatorNumber

    Tipo di dati

    float

    SWOG Treating Institution Number
    Descrizione

    SWOGTreatingInstitutionNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    NCI Thesaurus ObjectClass-3
    C41206
    UMLS 2011AA ObjectClass-3
    C1272753
    Other Group Treating Institution Name
    Descrizione

    OtherGroupTreatingInstitutionName

    Tipo di dati

    text

    Other Group Treating Institution Number
    Descrizione

    OtherGroupTreatingInstitutionNumber

    Tipo di dati

    float

    Protocol Privacy Approved Date
    Descrizione

    HIPAA Approval Date

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0600593
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2346844
    NCI Thesaurus Property
    C25425
    Radiology Lab Identifier Number
    Descrizione

    RadiologyLabIdentifierNumber

    Tipo di dati

    float

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C17059
    UMLS 2011AA ObjectClass
    C0034599
    NCI Thesaurus ObjectClass-2
    C37984
    UMLS 2011AA ObjectClass-2
    C0022877
    RT Physician
    Descrizione

    RTPhysician

    Tipo di dati

    text

    Treating Institution CTEP Code
    Descrizione

    TreatingInstitutionCTEPCode

    Tipo di dati

    text

    RT Facility
    Descrizione

    RTFacility

    Tipo di dati

    text

    Patient demographics
    Descrizione

    Patient demographics

    Patient's Social Security Number (If a U.S. resident)
    Descrizione

    Patient'sSocialSecurityNumber

    Tipo di dati

    text

    Gender
    Descrizione

    Gender

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0079399
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C17357
    Method of Payment
    Descrizione

    PatientPaymentType

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25371
    UMLS 2011AA Property
    C0680264
    Patient's Ethnicity
    Descrizione

    PatientEthnicGroupSouthwestOncologyGroupCategory

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C16564
    UMLS 2011AA Property
    C0015031
    Race
    Descrizione

    Racial Group

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS CUI-1
    C0034510
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C17049
    Patient's ZIP Code (If a U.S. resident)
    Descrizione

    Patient'sZIPCode

    Tipo di dati

    text

    Country of Residence, if not USA (if not USA)
    Descrizione

    CountryofResidence,ifnotUSA

    Tipo di dati

    text

    Social Insurance Number (If a resident of Canada)
    Descrizione

    PatientSocialInsuranceIdentifierNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C62650
    UMLS 2011AA ObjectClass-2
    C0728831
    NCI Thesaurus ObjectClass-3
    C16745
    UMLS 2011AA ObjectClass-3
    C0021672
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Patient's Date of Birth
    Descrizione

    PatientBirthDate

    Tipo di dati

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    Postal Code (If a resident of Canada)
    Descrizione

    PostalCode

    Tipo di dati

    text

    NCI Investigator Number
    Descrizione

    NCIInvestigatorNumber

    Tipo di dati

    text

    Patient Consent For Specimen Use
    Descrizione

    Patient Consent For Specimen Use

    My tissue and blood may be kept for use in research to learn about, prevent, treat, or cure cancer
    Descrizione

    SWOGPatientTissueConsentRelatedInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25460
    UMLS 2011AA Property
    C1511481
    My tissue and blood may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    Descrizione

    SouthwestOncologyGroupPatientTissueSpecimenConsentInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C25699
    UMLS 2011AA ObjectClass-2
    C1519429
    NCI Thesaurus Property
    C12801
    UMLS 2011AA Property
    C0040300
    NCI Thesaurus Property-2
    C19157
    UMLS 2011AA Property-2
    C0370003
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-3
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Someone from the Southwest Oncology Group may contact me in the future to ask me to take part in more research
    Descrizione

    PatientAdditionalResearchConsentInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25406
    UMLS 2011AA Property
    C1524062
    NCI Thesaurus Property-3
    C25460
    UMLS 2011AA Property-2
    C1511481
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Notes
    Descrizione

    Notes

    Notes
    Descrizione

    Notes

    Tipo di dati

    text

    Ritorna all'inizio della pagina

    Similar models

    No Instruction available.

    1 moduli
    1. StudyEvent: Southwest Oncology Group Registration Form (17418)
      1. No Instruction available.
    Name
    genere
    Description | Question | Decode (Coded Value)
    Tipo di dati
    Alias
    Item Group
    SWOG clinical trial administrative data
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16154 (NCI Thesaurus ValueDomain-2)
    C1704379 (UMLS 2011AA ValueDomain-2)
    Protocol Treatment Arm
    Item
    Treatment Arm Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1522541 (UMLS CUI-1)
    C32141 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    ActivationDate
    Item
    Activation Date
    text
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C64382 (NCI Thesaurus Property)
    C1879547 (UMLS 2011AA Property)
    C41200 (NCI Thesaurus Property-2)
    C0680532 (UMLS 2011AA Property-2)
    DataAmendedLastDate
    Item
    Last Amended Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    C25551 (NCI Thesaurus ValueDomain-2)
    C1517741 (UMLS 2011AA ValueDomain-2)
    Patient'sName
    Item
    Patient's Name
    text
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    Item
    Other Group Identifier Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C1257890 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CL.1
    Code List
    Other Group Identifier Code
    CL Item
    P9981_ncic2004791 (9981)
    CL Item
    Epp (9979)
    CL Item
    Ctsu (9976)
    CL Item
    P9997_rtog2004797 (9997)
    CL Item
    P9996_ncctg2004796 (9996)
    CL Item
    P9995_ecog2004795 (9995)
    CL Item
    P9987_mdacc2004794 (9987)
    CL Item
    P9984_gog2004793 (9984)
    CL Item
    P9977_acosog2004790 (9977)
    CL Item
    Nsabp (9983)
    CL Item
    P9982_calgb2004792 (9982)
    CL Item
    9977 - ACOSOG (9977 - ACOSOG)
    CL Item
    9981 - NCIC (9981 - NCIC)
    CL Item
    9982 - CALGB (9982 - CALGB)
    CL Item
    9984 - GOG (9984 - GOG)
    CL Item
    9987 - MDACC (9987 - MDACC)
    CL Item
    9995 - ECOG (9995 - ECOG)
    CL Item
    9996 - NCCTG (9996 - NCCTG)
    CL Item
    9997 - RTOG (9997 - RTOG)
    Study Number Participating Group
    Item
    Protocol Participating Identifier Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Caller'sSWOGRosterID
    Item
    Caller's SWOG Roster ID
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property-2)
    C1519429 (UMLS 2011AA Property-2)
    C25357 (NCI Thesaurus ObjectClass)
    C0557514 (UMLS 2011AA ObjectClass)
    IRBApprovalDate
    Item
    IRB Approval Date
    date
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25425 (NCI Thesaurus Property)
    C0205540 (UMLS 2011AA Property)
    ProjectedTreatmentBeginDate
    Item
    Projected Start Date of Treatment
    date
    InformedConsentDateSigned
    Item
    Date Informed Consent Signed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    SouthwestOncologyGroupInvestigatorIdentifierNumber
    Item
    SWOG Investigator Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C17089 (NCI Thesaurus ObjectClass-2)
    C0035173 (UMLS 2011AA ObjectClass-2)
    OtherGroupInvestigatorName
    Item
    Other Group Investigator Name
    text
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25936 (NCI Thesaurus ObjectClass-2)
    C0035173 (UMLS 2011AA ObjectClass-2)
    C43359 (NCI Thesaurus ObjectClass-3)
    C0441833 (UMLS 2011AA ObjectClass-3)
    OtherGroupInvestigatorNumber
    Item
    Other Group Investigator Number
    float
    SWOGTreatingInstitutionNumber
    Item
    SWOG Treating Institution Number
    text
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    C41206 (NCI Thesaurus ObjectClass-3)
    C1272753 (UMLS 2011AA ObjectClass-3)
    OtherGroupTreatingInstitutionName
    Item
    Other Group Treating Institution Name
    text
    OtherGroupTreatingInstitutionNumber
    Item
    Other Group Treating Institution Number
    float
    HIPAA Approval Date
    Item
    Protocol Privacy Approved Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0600593 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2346844 (UMLS CUI-2)
    C25425 (NCI Thesaurus Property)
    RadiologyLabIdentifierNumber
    Item
    Radiology Lab Identifier Number
    float
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C17059 (NCI Thesaurus ObjectClass)
    C0034599 (UMLS 2011AA ObjectClass)
    C37984 (NCI Thesaurus ObjectClass-2)
    C0022877 (UMLS 2011AA ObjectClass-2)
    RTPhysician
    Item
    RT Physician
    text
    TreatingInstitutionCTEPCode
    Item
    Treating Institution CTEP Code
    text
    RTFacility
    Item
    RT Facility
    text
    Item Group
    Patient demographics
    Patient'sSocialSecurityNumber
    Item
    Patient's Social Security Number (If a U.S. resident)
    text
    Item
    Gender
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0079399 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C17357 (NCI Thesaurus Property)
    CL.5
    Code List
    Gender
    CL Item
    Female (FEMALE)
    C46110 (NCI Thesaurus)
    C0086287 (UMLS 2011AA)
    CL Item
    Unknown (UNKNOWN)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Male (MALE)
    C46109 (NCI Thesaurus)
    C1706180 (UMLS 2011AA)
    Item
    Method of Payment
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25371 (NCI Thesaurus Property)
    C0680264 (UMLS 2011AA Property)
    CL.6
    Code List
    Method of Payment
    CL Item
    Private Insurance (Private Insurance)
    CL Item
    Medicare (Medicare)
    C16665 (NCI Thesaurus)
    C0018717 (UMLS 2011AA)
    CL Item
    Medicare And Private Insurance (Medicare and Private Insurance)
    CL Item
    Medicaid (Medicaid)
    C0025071 (NCI Metathesaurus)
    CL Item
    Medicaid And Medicare (Medicaid and Medicare)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Military Sponsored (including Champus & Tricare) (Military Sponsored (including CHAMPUS & TRICARE))
    CL Item
    Veterans Sponsored (Veterans Sponsored)
    CL Item
    Self Pay (no Insurance) (Self Pay (No Insurance))
    CL Item
    No Means Of Payment (no Insurance) (No means of payment (no insurance))
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Military Or Veterans Sponsored Nos (Military or Veterans Sponsored NOS)
    Item
    Patient's Ethnicity
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C16564 (NCI Thesaurus Property)
    C0015031 (UMLS 2011AA Property)
    CL.7
    Code List
    Patient's Ethnicity
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    No (not Spanish) (No (not Spanish))
    CL Item
    Yes, Mexican (Yes, Mexican)
    CL Item
    Yes, Puerto Rican (Yes, Puerto Rican)
    CL Item
    Yes, Nos (Yes, NOS)
    CL Item
    Yes, Central American (Yes, Central American)
    CL Item
    Yes, South American (Yes, South American)
    CL Item
    Yes, Other (Yes, Other)
    CL Item
    Yes, Cuban (Yes, Cuban)
    Item
    Race
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0034510 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C17049 (NCI Thesaurus Property)
    CL.8
    Code List
    Race
    CL Item
    Patient Refused Or Data Not Available (Not Reported)
    CL Item
    Patient Is Unsure Of Their Race (Unknown)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)
    C41261 (NCI Thesaurus)
    C0007457 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)
    C16352 (NCI Thesaurus)
    C0085756 (UMLS 2011AA)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of North And South America (including Central America), And Who Maintains Tribal Affiliation Or Community Attachment (American Indian or Alaska Native)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of Hawaii, Guam, Samoa, Or Other Pacific Islands (Native Hawaiian or other Pacific Islander)
    CL Item
    A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)
    C41260 (NCI Thesaurus)
    C0078988 (UMLS 2011AA)
    Patient'sZIPCode
    Item
    Patient's ZIP Code (If a U.S. resident)
    text
    CountryofResidence,ifnotUSA
    Item
    Country of Residence, if not USA (if not USA)
    text
    PatientSocialInsuranceIdentifierNumber
    Item
    Social Insurance Number (If a resident of Canada)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C62650 (NCI Thesaurus ObjectClass-2)
    C0728831 (UMLS 2011AA ObjectClass-2)
    C16745 (NCI Thesaurus ObjectClass-3)
    C0021672 (UMLS 2011AA ObjectClass-3)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    PatientBirthDate
    Item
    Patient's Date of Birth
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    PostalCode
    Item
    Postal Code (If a resident of Canada)
    text
    NCIInvestigatorNumber
    Item
    NCI Investigator Number
    text
    Item Group
    Patient Consent For Specimen Use
    Item
    My tissue and blood may be kept for use in research to learn about, prevent, treat, or cure cancer
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25460 (NCI Thesaurus Property)
    C1511481 (UMLS 2011AA Property)
    CL.2
    Code List
    My tissue and blood may be kept for use in research to learn about, prevent, treat, or cure cancer
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    My tissue and blood may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C1519429 (UMLS 2011AA ObjectClass-2)
    C12801 (NCI Thesaurus Property)
    C0040300 (UMLS 2011AA Property)
    C19157 (NCI Thesaurus Property-2)
    C0370003 (UMLS 2011AA Property-2)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.3
    Code List
    My tissue and blood may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Someone from the Southwest Oncology Group may contact me in the future to ask me to take part in more research
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15319 (NCI Thesaurus Property)
    C25406 (NCI Thesaurus Property-2)
    C1524062 (UMLS 2011AA Property)
    C25460 (NCI Thesaurus Property-3)
    C1511481 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Someone from the Southwest Oncology Group may contact me in the future to ask me to take part in more research
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Notes
    Notes
    Item
    Notes
    text
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